1、Appropriate Antibiotics use in CAP and HCAP at Sisters Hospital in 2008.Syed Faraz Masood,MBBSNashat H.Rabadi,MD,FCCPCommunity Acquired Pneumonia Common:5 to 6 million cases/year 20%are hospitalized(10%in ICU)No.1 cause of death from infectious disease No.6 cause of death in adults Mortality rates:O
2、utpatients=1-5%Inpatients=12%(higher in ICU-50%)Costs:9.7 billion :inpatient$7,517 vs.outpatient-$264 CAPDefinition CXR infiltrate Auscultatory findings Signs of RTI Cough+/-sputum Fever or hypothermia WBCCAP-Pathogenesis Aspiration Inhalation Hematogenous Direct extension Reactivation RESPIRATORY P
3、ATHOGENS IN CAPRespiratory Pathogens in CAPRisk Factors.Age.Smoking.Co-morbid Conditions.Poor Prognosis.Pleural Effusion.Bacteremia.Cultures.Sputum Cx Not needed as outpatient.May or may not be needed inpatient.Blood Cx Urinary Antigens.CURB-65C ConfusionU Urea.BUN 20R Respiratory rate 30/minB Blood
4、 pressure.SBP 90 or DBP 65Number of factors Mortality Rate 0 0.7%1 2.1%2 9.2%3 14.5%4 40%5 57%Management.Site of Care:Inpatient vs.outpatient.Floor vs.ICU.PSI CURB 65Empirical Treatment Hospitalized Patients:2nd or 3rd generation Cephalosporins plus a Macrolide.Floroquinolones.For all critically ill
5、 patients,2nd or 3rd generation Cephalosporin+Macrolide or Floroquinolones necessary to provide coverage for Legionella Pneumophilia.Change antibiotics based on culture and sensitivity.Nosocomial Pneumonia Hospital Acquired Pneumonia:48 hours of admission to hospital.Ventilator associated Pneumonia.
6、48 hours of intubation.Health-care Associated Pneumonia.Antimicrobial therapy in preceding 90 days.Hospitalization for 2 or more days in the preceding 90 days.Residence in a NH or an extended care facility.Home infusion therapy.Chronic Dialysis within 30 days.Immunosuppressive state and/or therapy.H
7、ealth-care Associated Pneumonia.Epidemiology extrapolated from HAP/VAP Second most common Nosocomial Infection.High morbidity/mortality.Increase hospital stay by 7-9 days.Excess cost of$40,000 per patient.Early VAP/HAP(5 days)treated similarly as HCAP:MDR pathogens.Microbiology Polymicrobial.Methici
8、llin-resistant Staphylococcus Aureus.Pseudomonas Aeruginosa.Acinetobacter E.Coli Klebsiella Pneumoniae(ESBL).Increased crude and attributable mortality associated with MDR pathogens.Pathogenesis of HCAP Colonization:Lower Respiratory Tract.Aspiration;inhalation.Host-related:severity of illness,prior
9、 surgery.Environment-related:antibiotic exposure,medications,invasive devices.Hosts mechanical,humoral and cellular defenses.Diagnosis Lower Respiratory Tract Cultures:Sputum Cultures.Endotracheal aspirates.Bronchoscopy Broncho-alveolar Lavage(BAL).Protected Brushed Specimen(PBS).Empirical Treatment
10、 Anti-pseudomonal cephalosporins or Anti-pseudomonal cabrapenems or Beta-lactam/beta-lactamase inhibitorsAnd Anti-pseudomonal floroquinolones.PLUS Vancomycin or Linezolid.HAP,VAP or HCAP SuspectedObtain Blood&Lower Respiratory Tract CulturesEarly,Appropriate,Adequate AntibioticsAssess Clinical Respo
11、nse Check Microbiology Clinical Improvement(24-48 hrs)YESNO Streamline Antibiotics.Treat Uncomplicated patients for 7 days.Reassess&Follow up.Search for Complications:Abscess or Empyema Untreated Pathogen Non-Infectious CauseATS Consensus Statement.AJRCCM 171:2005 Mortality in Nosocomial Pneumonia.P
12、resence of MDR pathogens.Initial Inappropriate antibiotics.Co-morbidities.Initial Inadequate Therapy Increases MortalityBAL=bronchoalveolar lavage.NS=Not significant.Luna CM,et al.Chest.1997;111:676-685.P.001P=NSP=NSAdequate Therapy Reduces Mortality Only If Selected Prior to Identification of the P
13、athogenResearch Question Appropriateness of CAP treatment at Sisters Hospital.Appropriateness of HCAP treatment at Sisters Hospital.Mortality.Length of Stay.Method IRB approval.HIPAA Compliance.248 charts reviewed with diagnosis of pneumonia.Retrospective analysis.Single institution(Community Hospit
14、al setting).1 Calendar year.(Jan 1st Dec 31st 2008)ClassificationCommunity Acquired PneumoniaGenderAnnual Frequency.Antibiotics administered in ER:100%Appropriate antibiotics:93.2%Cultures performed:95.7%Positive Cultures:8.1%CoverageCultures Positive CulturesMicrobiology of CAPChoice of Initial Ant
15、ibioticsMortality Number of Deaths:6/143 Mortality Rate:4.2%Average Length of Stay:5.8 days.Health-care Associated Pneumonia.GenderAnnual FrequencyMulti-Drug Resistant Risk FactorsInitial Antibiotic Coverage in ERInitial Antibiotics ChoiceOther Combinations used Vanco/Zithro Levaquin/Genta/Aztreonam
16、.Levaquin/Aztreonam Levaquin/Aztreonam/Clindamycin.Levaquin/Ceftazidime Aztreonam/Zithro Levaquin/Zithro Clindamycin Primaxin/Zithromax Levaquin/Clindamycin Zosyn/Zithromax Zosyn/Levaquin.Coverage.Appropriately changed within 24 hours of admission9.2%32%Appropriate Change in Subgroups in Covered Pat
17、ients.Positive Cultures Microbiology Appropriate antibiotics in ER:4.4%Partially appropriate in ER:15.5%Inappropriate antibiotics in ER:78.8%Appropriate change in 24 hours:16.27%Cultures performed:97.7%Positive cultures:18.1%Average Length of Stay:9.5 days Average age:71.2 yearsMortality Total Numbe
18、r of Deaths:11/90 Mortality Rate:12.2%Deaths on Inappropriate Antibiotics:9/11ComparisonVariablesHCAPCAPAge71.2 years69 yearsFemales71.5%54.5%Sputum Cx yield26.8%16.2%Blood Cx yield4.6%3.2%Urinary Ag yield10.8%2.4%Mortality12.4%4.2%LOS9.5 days5.8 daysHousestaff covered27.7%29.3%Wheres the problem?Pn
19、eumoniaCAPHCAPRECOGNIZE THE DIFFERENCEHAP,VAP or HCAP SuspectedObtain Blood&Lower Respiratory Tract CulturesEarly,Appropriate,Adequate AntibioticsAssess Clinical Response Check Microbiology Clinical Improvement(24-48 hrs)YESNO Streamline Antibiotics.Treat Uncomplicated patients for 7 days.Reassess&F
20、ollow up.Search for Complications:Abscess or Empyema Untreated Pathogen Non-Infectious CauseATS Consensus Statement.AJRCCM 171:2005 Strategies to Improve HCAP Outcomes Education.Order Sheets.De-escalation.Consultation.Re-evaluation.ReferencesNational Center for Health Statistics.Health,United States
21、,2006,with chart book on trends in the health of Americans.Available at:http:/www.cdc.gov/nchs/data/hus/hus06.pdf.Accessed 17 January 2007.American Thoracic Society;Infectious Diseases Society of America.(2005).Guidelines for the management of adults with hospital-acquired,ventilator-associated,and
22、healthcare-associated pneumonia.Am.J.Respir.Crit.Care Med.171(4):388416.Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit.The Influence of Inadequate Antimicrobial Treatment of Bloodstream Infections on Patient Outcomes in the ICU Setting*.Acknowledgement Dr.Nashat Rabadi.Cliff Gadra and the Medical Records team.Dr.Varuna Nargunan.Danielle Casucci.Dr.Sateesh Satchidanand IRB team.Thank You!
